PSA Screening

I didn't know I'd be commenting so soon on PSA screening.  This Week's American Journal of Public Health  has an article on men's understandnig of PSA testing:

Objectives. This study examined knowledge about prostate-specific antigen (PSA) screening among African Americans and Whites. Because PSA screening for prostate cancer is controversial, professional organizations recommend informed consent for screening.
Methods. Men (n = 304) attending outpatient clinics were surveyed for their knowledge about and experience with screening. Results. Most men did not know the key facts about screening with PSA. African Americans appeared less knowledgeable than Whites, but these differences were mediated by differences in educational level and experience with prostate cancer screening.
Conclusions. Public health efforts to improve informed consent for prostate cancer screening should focus on highlighting the key facts and developing different approaches for men at different levels of formal education and prior experience with screening

The study made headlines in the Reuters Health News this week:

A number of prominent groups, including the U.S. Preventive Services Task Force and the National Cancer Institute, are opposed to routine PSA screening, saying that the risks of follow-up tests and the side effects of treatment may outweigh the possible benefits for many men.

This is a good thing.  The mainstream press rarely discusses the fact that PSA testing is so complicated. 

I'm on the lookout for good PSA testing patient handouts.  Haven't found much.  The American Cancer Society's website recently featured this article on calls for informed consent prior to PSA testing.

But until physicians have good tools (educational materials) that will help them provide patients with adequate and reliable information, I'm not sure we'll be improving our track records much.  While I often try to have this discussion with patients, I find that it's a tough one to present in an unbiased manner.  Men who expect to have test done "because I get one every year .. cuz I'm supposed to" don't want to hear much about the complexity of this decision … and men who don't want to bother with any tests … don't want to bother with any tests .. so they don't get very engaged in the discussion either.

If you use .. or have seen good PSA education materials, please post a comment and share with the rest of us!


What is ISABEL?

 a sophisticated paediatric clinical decision-making support system designed as a near-patient working tool for doctors, nurses and health care workers

An analysis of the system was recently published (pdf)

It's free for physicians to create an account.  the system is easy and kinda fun to use.  YOu type in free twxt descriptions of the signs and symptoms, and the system attempts to develop a differential diagnosis.

It's easier to use than the "gold standard" decision support tool DXplain – but I wonder about how it does the parsing of the free text entries … what if I spell things wrong?

Patient – Initiated Testing

AMNews: May 5, 2003. Do-it-themselves diagnosis: Patients pick their tests

 This atricle from American Medical News highlights several intersting and problematic issues, yet overlooks the "patient-initiaed-testing" that occurs behind the closed doors of the physician's office.

"Doc .. I think I need an MRI" says the man with a headache.

He may .. but then again .. he may not.  Depending on the patient and the physician .. the decision to order the test or not will vary – even in the context of identical presentations of signs and symptoms.

A few weeks, ago, I saw a 39 year old for a sore throat.  He'll be 40 in a few weeks, and scheduled a visit for this event.  "I'll see you in a few weeks, Doc"  He says … "I'll need a full work-up at 40 .. y'know .. exercise stress test, chest x-ray, EKG, CBC and complete chem panel."

"oh boy" .. I says to myself … I'd better get the screening guidelines ready. 

So it gets tricky.  I do want to reassure him that he's healthy.  And I certainly want to do my best to keep him healthty.  But these tests simply aren't indicated. 

I usually bring up a copy of the guidelines on the web in the exam room so that we can discuss them.   Traditions die hard, though … and it's hard to educate away a fixed belief that something that was "essential" 10 years ago is no longer necessary.

Barbara Starfield has written about the importance of primary care .. but one of her most often cited papers is from 1994 in which she determines that lower cost care often provides the same quality of case as high cost care.

 .. and … in the context of last week's post on the Futures of Family Medicine project, Dr Starfield's lectures provide a wonderful outline of the reasons that Primary Care is better for a community than specialty care:

The last one is a fantastic overview of the complex pressures on health policy.  The 2nd half of the presentation includes a classic slide. Take a look at it carefully.  The Question it asks: should we do an exercise stress test on our patients before they begin jogging?  The answer:  No.  Doing the test may in fact expose them to greater risk than not doing the test. 

This is a concept that patients often find hard to grasp.   It comes up in the dicussion of PSA testing, of course … a discussion for another day.



This is the first non-medical post in a while … but bear with me .. we're just back from our long weekend in Montreal .. with a brief stop along the way home in Lake Placid.


Macromedia has released another product that simplifies the creation of rich internet applications.   Mike's post on the Flash MX Data Collection Kit reveals a bit about what Macromedia is inching us toward.  It's an interesting twist in the movement of the intelligence of an application .. and clearly it is what Macromedia thinks will represent is the next phase in the function of web-based applications.

  • Phase 1: The Web Was Born.  Simple servers respond to http requests and send back HTML pages. 
    • Dumb Servers
    • Dumb Clients (browsers 1.0)
  • Phase 2: Servers get smarter and interact with databases.  Browsers get smarter too
    • PHP, Coldfusion, .asp
    • Javascript, JAVA Applets, ActiveX Controls
  • Phase 3 (according to Macromedia) .. Move much of the business logic and processing code away from the server and onto the client – permitting the client to interact with the database intelligently.
    • Flash MX

It's interesting how this paralles the evolutions of database interaction in general.  Phase 1: have processing on the server side – with complex SQL required — and an expectation that many users would interact with dumb terminals.  Phases 2-3 brought richer clients – MS-Access, PowerBuilder, Visual Basic .. and even the whole .NET framework.

But the Flash MX method is much better than the "thick clients" of old .. since there is no application to install or update .. or find the missing .dll file … or fix the conflict .. or reinstall on the upgraded hard drive, etc etc.

The Web ironically shifted many "thick" client applications to "thin" ones again .. which constrained application designers (including most Electronic Medical Records vendors) .. as the web didn't offer a rich enough palette with which to paint their software.

So Macromedia now has tipped their cards, I think.  With the departure of Jeremy Allaire, former brainchild and Chief Coldfusion Evalgelist at Macromedia .. is seems that the development efforts are shifting away from Coldfusion MX, and toward the tools that will enable developers to create more robust clients – with or without  the browser.  Is this Bad?  I'm not yet sure.  I like Coldfusion very much, and  I think that the rich front-end certainly needs a robust back-end.  Developers should be able to choose the right tools for the job.  So .. if they do this right — and continue to devote adequate resoruces to Coldfusion .. it could go very well for Macromedia indeed.  But neglecting Coldfusion could backfire .. and could certainly alienate a generation of web developers.  I think that there is a real risk of this.  With Jeremy gone, and even Ben Forta writing more and more about the client side … no one seems to be keeping the CF fire burning.  It's been nearly a year since the release of "NEO" .. and there isn't much talk about what CF 7.0 is going to look like …


Weblog Comments

Quick post today .. .

a) BMJ has a new Interactive Case Report section


b) When I moved "Docnotes" from Userland Radio to Movabletype, I turned off the default template with "comments" on .. as I didn't think that it added much to the weblog.

Today, (at the request of several readers) .. I turned them on again … and noticed that comments may very well be good.

This comment on circumcision reminds me of the power of the weblog. 

…  OK .. we're off to the Expos game now ..